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. 2024 Jan;54(1):13-27.
doi: 10.4070/kcj.2023.0084. Epub 2023 Sep 19.

Risk of Atrial Fibrillation and Adverse Outcomes in Patients With Cardiac Implantable Electronic Devices

So-Ryoung Lee #  1   2 , Ji Hyun Lee #  3 , Eue-Keun Choi  1   4 , Eun-Kyung Jung  5 , So-Jeong You  5 , Seil Oh  1   2 , Gregory Yh Lip  1   6   7
Affiliations

Risk of Atrial Fibrillation and Adverse Outcomes in Patients With Cardiac Implantable Electronic Devices

So-Ryoung Lee et al. Korean Circ J. 2024 Jan.

Abstract

Background and objectives: Comprehensive epidemiological data are lacking on the incident atrial fibrillation (AF) in patients with cardiac implantable electronic devices (CIEDs). This study aimed to examine the incidence, risk factors, and AF-related adverse outcomes of patients with CIEDs.

Methods: This was an observational cohort study that analyzed patients without prevalent AF who underwent CIED implantation in 2009-2018 using a Korean nationwide claims database. The subjects were divided into three groups by CIED type and indication: pacemaker (n=21,438), implantable cardioverter defibrillator (ICD)/cardiac resynchronization therapy (CRT) with heart failure (HF) (n=3,450), and ICD for secondary prevention without HF (n=2,146). The incidence of AF, AF-associated predictors, and adverse outcomes were evaluated.

Results: During follow-up, the incidence of AF was 4.3, 7.3, and 5.1 per 100 person-years in the pacemaker, ICD/CRT with HF, and ICD without HF cohorts, respectively. Across the three cohorts, older age and valvular heart disease were commonly associated with incident AF. Incident AF was consistently associated with an increased risk of ischemic stroke (3.8-11.4-fold), admission for HF (2.6-10.5-fold), hospitalization for any cause (2.4-2.7-fold), all-cause death (4.1-5.0-fold), and composite outcomes (3.4-5.7-fold). Oral anticoagulation rates were suboptimal in patients with incident AF (pacemaker, 51.3%; ICD/CRT with HF, 51.7%; and ICD without HF, 33.8%, respectively).

Conclusions: A substantial proportion of patients implanted CIED developed newly diagnosed AF. Incident AF was associated with a higher risk of adverse events. The importance of awareness, early detection, and appropriate management of AF in patients with CIED should be emphasized.

Keywords: Atrial fibrillation; Cardiac resynchronization therapy; Implantable cardioverter defibrillator; Pacemaker; Risk factor.

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Conflict of interest statement

Eue-Keun Choi reported research grants or speaking fees from Bayer, BMS/Pfizer, Biosense Webster, Chong Kun Dang, Daiichi-Sankyo, Dreamtech Co., Ltd., Medtronic, Samjinpharm, Sanofi-Aventis, Seers Technology, Skylabs, and Yuhan.

Figures

Figure 1
Figure 1. Study enrollment flow.
AF = atrial fibrillation; CIED = cardiac implantable electronic device; CRT = cardiac resynchronization therapy; HF = heart failure; ICD = implantable cardioverter defibrillator; IR = incidence rate; PY = person-years.
Figure 2
Figure 2. AF-free survival curves in each cohort.
AF = atrial fibrillation; CRT = cardiac resynchronization therapy; F/U = follow-up; HF = heart failure; ICD = implantable cardioverter defibrillator; IR = incidence rate; PY = person-years.
Figure 3
Figure 3. Factors associated with incident AF in 3 cohorts.
(A) Pacemaker cohort. (B) ICD/CRT with HF cohort. (C) ICD without HF cohort. CAD = coronary artery disease; CI = confidence interval; HR = hazard ratio; MI = myocardial infarction; PAD = peripheral artery disease; TIA = transient ischemic attack; SSS = sick sinus syndrome; VHD = valvular heart disease.
Figure 4
Figure 4. Crude IRs of AF-related adverse outcomes in each cohort.
AF = atrial fibrillation; CRT = cardiac resynchronization therapy; HF = heart failure; ICD = implantable cardioverter defibrillator; IR = incidence rate; PY = person-years.
Figure 5
Figure 5. HRs of incident AF for AF-related adverse outcomes.
(A) Pacemaker cohort. (B) ICD/CRT with HF cohort. (C) ICD without HF cohort. AF = atrial fibrillation; CI = confidence interval; CRT = cardiac resynchronization therapy; HF = heart failure; HR = hazard ratio; ICD = implantable cardioverter defibrillator.
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